Laserfiche WebLink
UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed with its site identification number. <br />The Tracking Sheet is to be returned to Public Health Services within 30 days of acceptance of the tank by the disposal or <br />recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. <br />FACILITY NAME: Waterloo Food & Fuel <br />FACILITY ADDRESS: 3032 E. Waterloo Rd. <br />TANK ID #39 - Tank Description: 5000 gallon single wall steel <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor. Oil EQui pment- Servi rc- <br />Address: P.O. Box 950 City:San Andreas -Zip: 9r;?49 <br />Phone #: ( 2 0 9) 754-1808 Date Tank Removed: 2/16/99 <br />ssssssssisssis*s:ssssssssss*sass:#ss**iss*sssafasisssssaasaaassass::ssiiiss#isi#s#***ssa##sriiiisrrfilirrrs <br />SECTION 3 - To be filled out by contractor "decontaminating tank': <br />Tank Decontamination Contractor. Oil Equipment Service <br />Address: P.O. Box 950 City -.San .Andreas Zip: 95249 <br />Phone #: 209 754-1808 <br />Authorize <br />approved; <br />Signature; <br />yank has been decontaminated in an <br />Title: President <br />xeitn A.-Tatllia <br />sss#fsfs#*ssssrsstsssffsssssssrssssrssrss•si*isisrsssisssrssssss#sssssssssfssisiissst#issisrsrirsssilssiifr <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />accepting tank and/or piping. <br />Facility Name: Triangle Inc of Sacramento <br />Address: 3525 - 52nd Ave. City.Sacramento Zip: 95823 <br />Phone #: ( 916 4 21 1 9 9 0 <br />Date Tank Receb+ed: , 2/1-6/n <br />Title: 1 reS i deli <br />fiiitiliii ii iii#illi#t#ilf iltiiiiiiiit#tit#ti ii t••iffi#risiiiriii#•ii lilt l#til iiif#iiiif*tf tiittirifi•#i <br />EH 23 049 (Revised 7-10-92) Paye 10 <br />